PERFORMANCE BOND CNA FAST TRACK - Surety One€¦ · A. Bond: Any surety bond, undertaking, or other obligation in the nature of a guaranty or suretyship, as well as alterations,

Check and Complete:(check one only)

(For private jobs or subcontracts, please enclose a copy of the contract and bond form for projects over $150,000.)(For service type contracts, provide a copy of the contract.)

Bid Bond:Bid dateEstimated total amount of bid: $

OR Contract Price $

Any person who knowingly and with intent to defraud any insurance company or person files an application containing any materially false information or conceals,for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime under applicable law. Theapplicants and indemnitors certify the truth of all statements in the application and authorize the Company to verify this information and to obtain additionalinformation from any source including obtaining a credit report.

Performance & Payment Bond Supply Bond

AGENCY DATAAgency Name Agency Code -

Contract Date (Date when contract is signed)

Has the applicant been in claim, and/or, denied bonding by another surety?

CONTRACTOR DATAType of Business:

Company NameCompany Address City

Phone

Partnership LLCSole Proprietorship (S) Corporation (C) Corporation LLP

State ZipType of Work Date started in Business

E-Mail Address

Engineers Estimate: $Bid Bond %, or flat amount

Status of Outstanding Bid or Performance Bonds:

Bond No. Bid Awarded: Yes No

Bond No. Bid Awarded: Yes No

YesNo Explain (if yes)

NoneStand Alone Maintenance Bond $Subcontractor Performance & Payment Bond

$Next two lowest bidders

$

Bid secured by: Check NegotiatedBond

AIA FormCNA Form

Federal Contract #State of Incorporation

(Send copy)

(Send copy)

State FormObligee Form

BOND FORM DATAName of Agent signing as Power of Attorney

CNA Surety may obtain a credit report about the Applicant including its Owner(s) and Owners' spouses in order to confirm theinformation provided in this application and obtain information about Applicant's credit history. For new applicants, complete and signthe General Indemnity Agreement.

BOND REQUEST DATAAnticipated Start Date Time for Completion Maintenance PeriodObligee (Who is requiring the contractor get a bond?)

Job Legal DescriptionObligee Address

*This application is not intended for use in connection with Design-Build Contracts, Subdivision or Site Improvement over $100,000,Asbestos Abatement, Completion, Hazardous Materials, or Multi-Year Contracts where term of contract is over 5 years.

If no bond is needed at this time, but only prequalification for future bonding, check here

Job Physical Address

(Name here)

State ZipCity

State ZipCity

OWNER DATA / INDEMNITORS

SS#SS# DOB DOBSpouse NameSpouse Name

SS#SS# DOBDOBCity/State/ZipCity/State/ZipAddressAddressNameName

% of Business Ownership% of Business Ownership Married NoYes Married NoYes

(Provide the information below on all owners; use additional sheet if necessary)

C. POINDEXTER, SURETY ONE, INC. 3 2 1 7 9 1 7

PERFORMANCE BONDCNA FAST TRACK

Email: [email protected] | Facsimile: 919-834-7039

Mail: P.O. Box 37284, Raleigh, NC 27627

and

Complete this page for Aggregate Programs in excess of $350,000, up to $700,000.

FinalGross Profit

Location(City/County, State)

FINANCIAL DATA Please submit the following:Provide the company's last 2 years fiscal year-end financial statement or tax return. Ifthe latest fiscal year financial statement or tax return is more than 6 months old, thenalso provide a current interim financial statement.

Company Financial Requirementsfor (C) Corporations, (S)Corporations, and LLCs:

Contractor's Company Name

Contractor's Company Address

File Number(s) Reference

StateCity Zip

AGENCY DATAAgency Name Agency Code -

ContractPrice

YearCompleted

Provide a copy of each owner's latest personal financial statement. If the personalfinancial statement is more than 6 months old then provide us with a current statement.

Personal Financial Statements

Business Financial Requirementfor Sole Proprietorships andPartnerships:

orProvide the last 2 years fiscal year-end financial statement on the business. If thefiscal year-end statement on the business is more than 6 months old, then alsoprovide us with a current interim financial statement.

Does the contractor have a formal bank line of credit? NoYesAmount currently borrowed?

List the two largest jobs you presently have underway, giving the following information:

Owner or General Kind of WorkDate to beCompleted

EstimatedGross Profit

ContractPrice

% ofCompletion

Location(City/County, State)

a. Failed in business or declared bankruptcy?b. Failed to complete a job or been assessed with delay damages?

Any officer, owner or partner

Yes NoYes No

. . .. . . . . . . . . . . . . . . . . . .

Company

Yes NoYes No

GENERAL DATADisputes, Financial Difficulties, Problems, Etc.

f.

c. Been involved in any lawsuits or disputes in the last 5 years? Yes No . . . . . Yes Nod. Do you have any corporate or personal assets

held in trust or escrow accounts?

Yes NoYes No

. . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . Yes NoYes No

e. Are any business or personal assets restricted or pledgedfor any purpose (i.e. collateral for a loan, etc.)?

Yes NoYes No

Were you bonded in the past - By whom? . . . . . . . . . . . . . . . . . . . . .

OPERATIONS DATA

Type of trades you perform:•Liability Insurance Company and Limits Expiration Date / /

Trades subcontracted:•Territory in which you perform work (present and planned)•

Explain all "yes" answers fully below or attach explanation

EXPERIENCE DATAList the three largest contracts completed in the last five years:

Owner or General Kind of Work

If "Yes" amount of Line of Credit?

C. POINDEXTER, SURETY ONE, INC. 3 2 1 7 9 1 7

A. Bond: Any surety bond, undertaking, or other obligation in the nature of a guaranty or suretyship, as well as alterations, amendments, extensions, substitutions, andrenewals issued or procured by the Surety on, before, or after the date of this Agreement for (a) any Indemnitor or any of their respective parent companies, subsidiaries, andaffiliates; (b) any joint venture, partnership, association, limited liability company, or other legal entity in which one or more of the persons and entities identified above insub-paragragh (a) have a direct or indirect interest; or (c) at the request of any Indemnitor.

F. Surety: Any one or more of Western Surety Company, Universal Surety of America, and their successors, assigns, affiliates, subsidiary companies, and reinsurers. The term Surety shall also include any other person or entity which, at the request of the above, may act as surety or co-surety on any Bond.

A. To defend, indemnify, and save harmless Surety from and against any and all Loss Indemnitor which the Surety may pay or incur.

GENERAL INDEMNITY AGREEMENT

GENERAL PROVISIONS. The Indemnitors further agrees as follows:A. Books and Records; Credit Reports. Upon demand and reasonable notice, the Surety shall be provided access to the books and record of the Indemnitors which

includes but is not limited to papers, books, records, contracts, reports financial information and electronically stored information for the purpose of review and copying. TheSurety is authorized to obtain a credit report on any Indemnitor at any time while the Surety may be liable under any Bond.

THIS AGREEMENT is made by the undersigned Indemnitors ("Indemnitors") for the benefit of Surety in connection with any Bond, as defined below, which may have been ormay hereafter be provided for the benefit of or at the request of any one or more Indemnitors. If any Indemnitors have previously executed an indemnity agreement in favor ofSurety, this Agreement shall be in addition to and not in lieu of or in replacement of such other agreement.

I. DEFINITIONS. The following terms shall be defined as follows for purposes of this Agreement:

B. Contract: Any contract or obligation whose performance is covered or guaranteed under a Bond.C. Event of Default: Any one or more of the following: (a) any breach of the terms and conditions of this Agreement; (b) Principal's breach, abandonment or forfeiture of a

Contract; (c) any bankruptcy, insolvency, assignment for the benefit of creditors, appointment of a receiver or conservator, or similar proceeding concerning the Principal or anyIndemnitor, whether voluntary or involuntary.

D. Loss: Any (a) claim, demand, liability, charge, suit, fee, or expense, including but not limited to attorney (both outside and in-house) and consultant fees, incurred by theSurety as a result of issuing or procuring a Bond; (b) cost incurred by Surety in procuring or attempting to procure a release from liability under a Bond; (c) cost incurred ininvestigation or adjustment of any claim or potential claim under a Bond; (d) costs incurred by Surety in enforcing the Indemnitors' obligations under this Agreement; and (e) anyother cost incurred by Surety arising from the issuance or procurement of a Bond. The term Loss shall also include any advances or loans to any Principal or Indemnitor thatare not repaid to the Surety as required by the terms of such advances or loans.

E. Principal: The person(s) and entity (ies) whose Contract obligations the Surety is requested to guarantee by issuing or procuring a Bond. Principal includes any personor entity identified on a Bond as "Principal" or "Contractor."

II. INDEMNITY. The Indemnitors agree:

B. To pay Surety all premium due on Bonds at the rates and times specified by the Surety. The Indemnitors specifically acknowledge and agree that the Surety's right tocharge and collect premiums continues until the Surety is provided written evidence, satisfactory to the Surety that (i) its liability on such Bond has been discharged or (ii) itstermination of liability as a matter of law.

C. That in any claim or suit arising out of or related to any Bond or this Agreement, an itemized statement of Surety's loss and expense, sworn to by a representative ofSurety, or other evidence of disbursement by Surety, shall be prima facie evidence of the fact and extent of Indemnitor's liability under this Agreement.

D. To deposit collateral security with the Surety upon demand in an amount that Surety shall reasonably determine is necessary to protect it from Loss whether or notSurety has made any payment.

E. That in the Event of Default: (a) the Surety shall have the right, but not the obligation, to take possession of the work under any Contract, to complete such Contract, orcause or consent to the completion thereof, with any cost thereof being Loss; (b) the Indemnitors hereby assign, transfer, and set over to the Surety all of their rights under theContracts, including: (i) their right, title and interest in and to all subcontracts let in connection therewith; (ii) all machinery, plant, equipment, tools and materials upon the site ofthe work or elsewhere for the purposes of the Contracts, including all material ordered for the Contracts; (iii) all patents, licenses, permits and computer software used for theperformance of any Contract and/or financial record keeping of the same; (iv) all actions, causes of action, claims and demands whatsoever relating to the Contracts; and (v)any and all sums due under the Contracts at the time of the Event of Default or which may thereafter become due; (c) the Indemnitors hereby authorized the Surety to endorsein the name of the payee, and to receive and collect any check, draft, warrant or other instrument made or issued in payment of any such sum, and to disburse the proceedsthereof; and (d) the Indemnitors hereby irrevocably nominate, designate and appoint the Surety and its designees as their attorney-in-fact with all the powers necessary toexercise any right granted in this Agreement, including but not limited to the power to make, endorse, execute, sign, and deliver any and all additional or other instruments,checks, drafts, deposits, ACH and wire transfer directives and orders, change of address notices, liens and releases thereof, applications, certificates, draw requests, orders,releases, and papers deemed necessary or desirable by the Surety in order to give full effect to the obligations assumed and the agreements made by Indemnitors hereunder,the assignments and conveyances made herein, and the full protection intended to be herein given to the Surety under all the provisions of this Agreement. The Indemnitorsratify and confirm all acts undertaken by the Surety and/or its designees as such attorney-in-fact.

F. That all payments earned on any Contract shall be held in trust as trust funds for the completion of the Contract and the payment of Indemnitors' obligations for labor,material, equipment, supplies or services furnished in the performance of the Contract. Upon an Event of Default and the Surety's request, Indemnitors shall open an accountwith a bank acceptable to the Surety for the deposit of such trust funds.

G. That upon an Event of Default, the Indemnitors grant the Surety a security interest in all property, rights, and assets of the Indemnitors, including, but not limited to, allinventory, equipment, instruments, investments, contracts rights and proceeds, insurance, accounts, and deposits ("Collateral"). This Agreement shall constitute a SecurityAgreement and a Financing Statement for the benefit of the Surety in accordance with the Uniform Commercial Code and any similar statute and may be so used by the Suretywithout in any way abrogating, restricting or limiting the rights of the Surety. Indemnitors authorize the Surety upon an Event of Default to file this Agreement or a photocopythereof and any schedules or statements necessary to describe the Collateral covered by such filing.

III.

B. Joint and Several Liability. Indemnitors' obligations under this Agreement are joint and several. Surety's release of any one Indemnitor shall not release any otherIndemnitor. No action or inaction of Surety with respect to anyone other than Indemnitor shall relieve the Indemnitor of any obligation owned under this Agreement. Indemnitorshall not be released from liability under this Agreement because of the status, condition, or situation of any party to this Agreement or any Principal.

C. Defects in Execution. If the execution of this Agreement by any Indemnitor is defective or invalid for any reason, such defect or invalidity shall not affect the validityhereof as to any other Indemnitor. Should any provision of this Agreement be held invalid, the remaining provisions shall retain their full force and effect.

D. Prior Bonds. Indemnitors waive any defense related to the date of this Agreement's execution and acknowledge that any and all Bonds executed pursuant to anyIndemnitor's request before the date of this Agreement were executed by the Surety in reliance on this Agreement. Indemnitors understand and agree that this Agreement is acontinuing agreement to indemnify over an indefinite period.

E. Claim Notices. Immediately upon becoming aware of any claim, demand, or proceeding concerning a Bond, the Indemnitors shall send notice of same to the Surety at:CNA Surety Corporation, Claim Department333 South Wabash Avenue, 41st FloorChicago, Illinois 60604

F. Claim Settlement. Surety shall have the right in its sole discretion to decide whether any claims arising out of or related to any Bond shall be paid, compromised,defended, prosecuted, or appealed regardless of whether or not suit is actually filed or commenced against Surety upon such claim. Absent Surety's intentional wrongdoing,Indemnitor agrees to be conclusively bound by Surety's resolution of any and all claims and to accept Surety's determination of liability in regard to any and all claims.

(As listed on questionnaire)

PLEASE NOTE: Indemnity is required of the entity AND all owners and spouses personally. (1) Provide theindemnity of the entity by dating and signing with authorized title below. (2) All owners and spouses must signas personal indemnitors. Refer to the boxes at right for examples of proper indemnity by indemnitor type. BYSIGNING THIS INDEMNITY, INDEMNITORS ARE ACKNOWLEDGING THEY HAVE READ AND ARE AGREEING TOBE BOUND BY ALL OF THE TERMS AND CONDITIONS ON PAGES ONE AND TWO OF THIS DOCUMENT.

(1) Dated:(Month) (Day)

,(Year)

,

Company Name (Print):

(Printed)

AuthorizedSignature X Title:

Title:

Indemnitor Type:PersonalSpouse

Proper Indemnity:John Doe, IndemnitorJane Doe, Indemnitor

(2)

G. Bond Declination. Surety may decline to execute any Bond for any reason and shall not be liable to Indemnitor, or any person or entity, as a result of such declination.H. Termination. An Indemnitor may terminate liability to Surety under this Agreement by sending written notice by registered mail of intent to terminate to Surety, in care

of Western Surety Company, P.O. Box 5077, Sioux Falls, South Dakota 57117-5077. Termination will be effective twenty days after actual receipt of such notice by Surety, onlyfor Bonds signed or committed to by Surety after the effective date of termination.

L. Other Agreements. Indemnitors agree that this Agreement is not a replacement, release, or alteration of any other agreement between any Indemnitor and the Suretybut shall be in addition to such other agreement unless expressly stated otherwise herein.

M. Amendment; Assignment. This Agreement may not be altered or amended except by a writing executed by the Indemnitors and the Surety. This Agreement and theIndemnitors' obligations hereunder may not be assigned without the prior written consent of the Surety.

N. Date of Agreement. The date of this Agreement shall be the earliest date that any Indemnitors executes this Agreement.

I. Issuing Surety. Indemnitors understand and agree that other than for the entity issuing a Bond, no other entity included within definition of the "Surety" in this Agreementassumes any obligation whatsoever with respect to either this Agreement or such Bond.

J. Electronic Image. An electronic image, printout, copy, or facsimile of this Agreement shall be considered an original and shall be admissible in a court of law to thesame extent as an original copy.

K. Bond Changes. The Indemnitors' obligations to the Surety shall remain unchanged in the event of any changes in any Bond without regard to notice or consent by anyIndemnitor. The Surety shall have no obligation to give the Indemnitors notice of the execution, renewal, or modification of a Bond.

Indemnitors: Signature XSpouse: (Printed)(Printed)

Indemnitors: Signature X

Indemnitors: Signature XSpouse: (Printed)(Printed)

Indemnitors: Signature X

Indemnitors: Signature XSpouse: (Printed)(Printed)

Indemnitors: Signature X

Indemnitors: Signature XSpouse: (Printed)(Printed)

Indemnitors: Signature X

Entity Type:Sole ProprietorPartnershipCorporationLLC

Proper Indemnity:John Doe, OwnerJane Doe, PartnerJohn Doe, PresidentJane Doe, Managing Member